The WORST-CASE SCENARIO Survival Handbookidaho.aoa.org/Documents/ID/CongressOD2016/survival_guideidaho... · The WORST-CASE SCENARIO Survival Handbook ... • Need to control accom

Presented by Dr. Raymond Chu at Idaho Optometric Physicians Annual Congress 2016

The

WORST-CASE SCENARIO

Survival Handbook

By Raymond Chu, OD MS

I certify:

• I have no proprietary interest in the tested

product

• I have no equity interest or significant payments

by the sponsor of a covered study

• Lecture content and

format is free from

commercial bias

• Lecture content was

independently

prepared by myself

Fix Follow Maintain

• Monocular

• Fixate on an object

• Follow the object into

various gaze positions

• Maintain fixation

Binocul Vis Strabismus Q. 2001;16(2):85-90.

The use of the FFM is so insensitive, and so

unspecific, that it’s virtually useless.

Fixation Preference

• Screening test for

strab & amb

• Sensitive to > 3 line

difference

• Dissociate: 10 BU

Sensitivity (specificity):

• aniso 20% (94%)

• strab 69% (79%)

Cotter et al. Ophthalmology 2009

Teller Acuity Cards (TAC)

• Designed for 6 months to 3 yrs

• Median time: 3.2 - 8.4 min

• Repeatable ± 0.5 octave

• 1 octave IOD is significant

• 30 cpd ≈ 20/20 Snellen equiv.

Precision-Vision

Full set: $3929

½ set: $2131

Keeler Acuity Cards

Richmond Products: Set of 18 cards $1,800.00


LEA Grating Test

• Same principle as TAC

• Designed for 12 months to 2 yrs

Good-Lite: $250

Cardiff Acuity Test

• Vanishing optotype

• Avg admin: 3-5 min.

• Designed for 6 months

to 3year olds

• 3 cards per acuity level

• Threshold: 2/3 correct or 3/4

• Can be used in cases of

suspected malingering

Richmond Products: $1800

LEA

• Matching / ID

• Well standardized for 2+ year

old children

• VIP study: Superior to HOTV

test in 3 y.o.

• Crowding ↑ sensitivity for

amblyopia

• IOD >1 line may be significant

LEA

• Matching / ID

• Well standardized for 2+ year

old children

• VIP study: Superior to HOTV

test in 3 y.o.

• Crowding ↑ sensitivity for

amblyopia

• IOD >1 line may be significant

Picture Chart

Patti Pics

Wright figures

Visual acuity for preschoolers

• Isolated single optotype

• High-contrast optotype

• Without directional

component

• A matching response

• Presented at 3m


HOTV

• Letters do not blur out equally

• 3-5 yr olds

• VIP study: 4 y.o. HOTV or LEA

• Test @ 10 ft.

• ATS study: ± 1 line

Dry Retinoscopy• Need to control accom and on-axis

• Phoropter vs lens bars

• Refracting glasses

• Don’t forget to subtract WD

Richmond Products: $115-120

Trial Frames

Richmond Products

Set of 5: $100

$27 each

Mohindra/ Near Retinoscopy

• 50 cm working distance

• Dark room illumination

• Ret beam: minimal intensity

• Occlude non-tested eye

• Correcting factor -1.25 D

• Borghi and Rouse (1985): Cycloplegia

revealed +0.50 to +0.75 D more plus than

near retinoscopy

Cycloplegic Agents

Infant (<1 yr):

2 drops, 0.5% cyclopentolate

spaced 5 min apart

Child (≥ 1 yr):

2 drops, 1.0% cyclopentolate

spaced 5 min apart

Gulden Ophthalmic: $22.00 / dozen

Wet Retinoscopy

• For Strab: occlude non-

tested eye

• Increase in aberrant

reflection


Autorefraction

• Non-cyclo = not reliable

• Diagnostic only when

cyclopleged

EOM

Doll’s Head Reflex

(oculocephalic reflex)

Brückner

• WD: 1 meter

• Room illumination:

Dark

• Brighter reflex =

suspected eye

Hirschberg

• Corneal reflex

displacement

• Nasal = (+)

• Temporal = (-)

(+)

(-)

12 mm

4 mm

Kappa Test

1 mm displacement = 22D

Cover Test

Ensure fixation and

accommodation on target

http://video.google.com/videoplay?docid=-6352718844936995767

http://video.google.com/videoplay?docid=-6352718844936995767


Pediatric Flashlight Stereopsis

RDS E

Lang II

Testability

86% for 3 yo,

89% for 4 yo,

93% for 5 yo

No polaroid

glasses needed

Preschool

Assessment of

Stereopsis with a

Smile (PASS)

Richmond

Products:

$158

Bernell

Good-

Lite:

$178-

389

StereopsisAmong children aged 3 yrs 0 months

through 3 years 6 months

Stereopsis

Preschool Randot Test

Stereo Fly

Randot Stereo Test

Good-Lite:

$189Good-Lite:

$189

Latham and Phillips Ophthalmics: $365

Randot Preschool Stereoacuity

Test

J AAPOS 2008;12:23-26

Binocular & Accommodative testing

Subjective

• Phorometry

• Risley prism

vergence ranges

• Accom Amps &

Facility

• NRA / PRA

Objective

• NPC

• Cover Test

• Prism bar vergence

ranges

• MEM


Confrontation VF

• @ 6-7 months, ~93% of an adult

Color Vision

Cotter et al (1999): 100%

sensitivity and 90.5%

specificity in screening of

kindergartners (5-7 yrs)

X-link recessive:

1:12 boys and 1:200 girls

have color deficiency

Bernell: $99.95

Richmond

products:

$279

IOP

Standard of care in school age

children

Veatch Ophthalmic:

$3990

IOP

Icare

$3750

Tonopen vs GATBaseline Characteristic N (%)

Average Tonopen IOP (OD, mmHg)

≤11 58 (12)

11 to 16 313 (66)

16 to 21 146 (31)

>21 22 (5)

Mean (range) 15.4 (6 to 25)

Average GAT IOP (OD, mmHg)

≤11 68 (14)

11 to 16 313 (66)

16 to 21 90 (19)

>21 2 (0.4)

Mean (range) 14.2 (8 to 23)

Dilating Agents

• Phenylephrine 2.5%

– Don’t use in <3 yo

or hx of

cardiovascular

problems

– No effect on accom

• Tropicamide 1%

– Safest dilating agent


Anterior Segment Evaluation

$2980-4260

EIDOLON Hand

Held Slit Lamps

5x magnification

Eidolon: $595

Bluminator / 20 + transilluminator

7x image

Eidolon

Set of 10: $675

$75/each

Poterior Segment Evaluation

• MIO: 5x, ~45o

• BIO: ~2.5x, ~35o

• DO: ~15X, ~6.5-10o

Optos

• ~ 200o view without

dilation

• The younger the child,

the more difficult the

setup

Examination of the infant/toddler

1. Hx

2. Teller / LEA

grating / Cardiff/

Fixation

preference

3. EOM, NPC

4. Hirschberg &

Kappa &

Brückner

5. MEM

6. Ant seg eval,

pupils

7. Cyclo ret

(0.5% for <1 yr)

8. Post seg eval

Examination of the preschooler

1. Hx

2. LEA (3 or 4) or

HOTV (4) VA’s

3. EOM, NPC,

Cover Test, Stereo

4. Dry ret

5. MEM

6. Ant seg, pupils

7. Color vision OU

8. Cyclo ret

9. Post seg